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Based on medical record review and interviews, the Hospital failed to ensure all documentation for 6 records (#1, #3, #4, #5, #9 and #10), reviewed for discharge planning in a sample of 10 were dated, timed and authenticated.

Findings include:

1,) For Patient #1, the Patient Discharge Instructions/Page #1 Patient Care Referral was not dated, nor was the time documented.

2.) For Patient #3, the Patient Discharge Instructions/Page #1 Patient Care Referral was not dated, timed and signed by a registered nurse as required by Hospital policy.

3.) For Patient #4, the Patient Discharge Instructions/Page #1 Patient Care Referral and the electronic discharge instructions were not signed by Patient #4 and the form was not dated and timed.

4.) For Patient #5, the computerized discharge instructions were not signed by Patient #5 on the space provided for signature.

5.) For Patient #9, the electronic discharge instructions for Patient #9 were in the record, however, the instructions were not signed by Patient #9 on the space provided on the form.

6.) For Patient #10, Patient Discharge Instructions/Patient Care Referral Page 1 was not timed. The Patient Discharge Instructions/Patient Care Referral Page 1 did not contain an RN signature not were the instructions signed by Patient #10.

Based on observation, interview and record review the Hospital failed to ensure that all necessary information was received by a home care agency to provide nursing services for one (Patient #1) of 10 patient records reviewed.

Findings include:

1.) The Complainant was interviewed on 9/21/11 at 11:40 AM. The Complainant said Patient #1 was discharged from the Hospital on 8/27/11 to the rest home on a Saturday. Patient #1 was scheduled to received diabetic services from a home care agency that provides skilled nursing services that are not available at the rest home. The Complainant said the Hospital faxed the referral information to the home care agency on Saturday, 8/27/11, but the home care agency was closed. The Complainant said the faxed referral was found two days later on Monday, 8/29/11, when the office opened and the skilled services were initiated that evening.

2.) Review of Patient #1's medical record indicated the referral information was faxed from the Hospital to the home care agency, however, the medical record lacked documentation the faxed referral information was received by Health Care Agency #2. As a result, the Hospital did not have confirmation that this service would be provided on Saturday, 8/27/11 and Sunday, 8/28/11 as required.

3.) Review of Patient #1's discharge Medication Reconciliation Form, completed by Patient #1's attending physician, indicate that for one week after discharge, Patient #1 was to have a capillary blood glucose (CBG level) checked before each meal and at bedtime and Humalog Insulin would be administered before each meals and at bedtime according to the CBG level. Because services were not initiated, Patient #1 did not receive services as requested by the physician.